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A27 120A�aiication Date: � -�3� " Tax Map #: /d � � � Amount Paid: 0 .0 0 Recsiat �: ParcEi #: ( �� `��� �,�� �� �Jl�1L�l.� �� �3�c -' � = �c����� �Cnav�aa-oa-a.-�-�-•• .aa�a.��.Il. IE��io.I1.�I�a APPLICATtON FOR SERVICES . IF THE INFORMATI�N IN THE APPLICATION FOR AN IMPROVEMENT PERMIT IS INCORRECT. FALSIFtED, CHANGED. OR THE SITE IS ALTERED. THEN THE IMPROVEMENT PERMIT AND AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. �. , , / 1) Permit requested by: (Ownerlagentlp Home Phone: Business Phone� � �iba 2) Name and address of current owner. 3 Pro e Descri tion: Lot size: � ) p rty p 3,���Y�sTownship: � P �� Subdivision: �1— Lot#�_ Directions to the prope�ty (InFluding roa�l names and nurrtbgrs). , fT, ,,._ 4) F�roposed Use and Structure Description: answer each of the following questions: a) Proposed , Existing J Type of Structure: Width: Depth: b) Number of Bedrooms: Number of occupants or people to be served: c) Basement: Yes , No Will there be plumbing in the basement? d) 6arbage Disposal: Yes _, No _ 5) Water Supply Type: Private �(new � or existin , Public_, Community� , Spring _ Are any wells on adjoining property? Yes�No _ If yes, please indicate approximate location on the 'site plan. 6) Does your property contain previously identified jurisdictional wetlands? Yes_ No � PLEASE NOTE THE FOLLOWING: ➢ A PLAT OF THE PROPERTY OR SITE PLAN MUST BE SUBMITTED WITH THIS APPLICATION. ➢ PROPERTY LINES AND CORNERS MUST BE CLEARLY MARKED. ➢ THE PROPOSED LOCATION OF ALL STRUCTURES MUST BE STAF(ED OR FLAGGED. ➢ THE SITE MUST BE READILY ACCESSIBLE FOR AN EVALUATION BY THE HEALTH DEPARTMENT STAFF. I hereby make application to the Person County Health Department for a site evaluation for the on-site sewage disposal system for t above-described pr rty. I agree that the contents of this application are true and represent the maximum facilities t e pla ed n the o . I understand if the site is altered or the intended use hanges, the permit shall beco valid. c �� �� � Owner or Lega Representative Da PCN�, ��. os�27ioz ... ,., .-: ..•b: . . ,:. ,: - _ - - ,. ; :: . : � . .. :: ,.. - -, . ,. . . . . _ . ,. . . ;: . : . . �. , , - - � .. -. , �. , ..._ .. _ � ,, . . . . ,. . _ , � .,. � ,`,/` . . ` � . - . Wo `° w 2.63�dc � .. N �.� . . .. _ .. . .. 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(� � tC7�TvII�� ]��n�n��angn�n�c;n�n��n.� �"��:.tn.���in Applicant: Location: K Permit Valid for �Five Ye Type of Facility: ��� # of Occupants Ct # of Proposed Wastewater System: Proposed Repair: �h� PPrmit C'.nnc�itions: Tax M�� 1i - P�rcel # - �' Swhcl'ivi�s�ioi� ' � Pha�se SecNt�ion Lot � ' Improvement Permit _ No Expiration ��( edrooms G( New � Addition Water Supply Projected Daily Flow � �� g.p.d• � a�� Type: Type: � �Pp�� �t.�S'�r� a,� �� S¢' ipd r Owner or Legal Representativ Si ture: Date: Authorized State Agent: � vWv Date: —'� _ The issuance of this permit by the Health Department in does not guarantee the issuance of other permits. It is We responsibility of the applicant/property owner to in sure that all Person County Planning and Zoning and Building Inspections requirements are met. This Improvement Permit is subject to revocation if the site plan, plat or the intended use changes. The Improvement Permit is not affected by a change in ownership of the property. Tlus permit was issued in compliance with the provisions of the North Carolina `Laws and Rules for Sewage Treatment and Disposal Svstems' (15A NCAC 18A .1900). Neither Person County nor the Environmental Health Specialist warrants that the septic tank system will continue to function satisfactorIIy in the future or that the water supply will remain potable. Authorization to Construct Wastewater System �Required for Building Permit) ��av� a�- * See site plan and additional attachments (__J. � Z ��,� Proposed Wastewater System: vfd�C}. `V`�- Type �� Wastewater Flow ���g.p.d. New � Repair Expansion _ Soil LTAR: � 3� g.p.d./ ft 2 Tyre �f Facility: � �l'.- Basement _ Yes '� No Wastewater System Requirements Tank Size: Septic Tank: � gal Pump Tank: �f�0 V gal Grease Trap: gal Drainfield: Total Area: ��� sq ft Total Length > 2o ft Maximum Trench Depth l� a�in Trench Width � ft Minimum 5oi1 Cover: � in Minimum Trench Separation: � ft���� Distribution: Distribution Box Serial Distribution � Pressure Manifold Specifications: Authorized State Agent: � Permit Expiration Date: The type of system permitted is the permit. Owner/Le�al Reuresentative: S d�t;V"1J'�' Date: 7r "v � Conventional � Innovative Alternative. I accept the specifications of Date: � .. ... . , . . .. . ' r . . . . . . .. . y . ; _ . . . � . . . 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" �:. � � : �..�,�` _ . � 'Y. ;. .. _ _,. : . ::: _ ..•':;,:..'.' y w : � , � � � - t'y �... ,. � .. � �. � - . � � w: . , . . . .,,��„ . � � � - � o. . �°� . : - � .._ _� . . . - � - . - .:.. . � . � N '�: _ - . � � . � � - - �� ; ,,� � � . � � �� ` ` C�'��: � UvQc �;V-���1`D( �t►� (,r'�`�s�I e�cr�b � �� _ , ��_ .. . _ _� . � . , �-�:� . . , � A � . � , _ �, . � -. . . -� , . -, . . : ���,�(:�� �� :1�� . �. �s p� s s�� ���F � = . . . . . : � .�����- x .: :.. :� ; � - _ ----� _._ -- :. .� : :1 . . . .. . � . � � C� .� � ' . . .� .�. ��r�r��S � `�� ��,���. � . _ _-_ � � - _ _ �,,,,.�u,� 1�,.��,,� r ���. :���;�� ���� �� �� �`� ', << � � r �, � � ���Tl��� ��-��-�,.T,.,�,.��,.�.� ���.��� SITE. SKETCH Name '� S�-2�� _ Tas 1VIap #�2 Parcel # 1� � Su ' ' ion �� Secti.on/Lot# g ,rv�e� � 9-� Authorized State Agent � Date System components represent approximate �contours only. The contractor must, fTag the rystem�irior to beginning the installation to insure thatproj�ergraate is maintained �—��, ; , � � ���� `l_l�� (���CL C� `� � �� 1 � � � ���� J 1�� lE�-�-�� � ¢�.11 ]HL�.�.11�� O er: ��►�'l�n Tax Map: � Parcel #: �� D : � I,ine Tap Tap (Sch) Tap �'lo� Line Le�gth �'iow / foot # Diameier ia) ( m) �;. (ft) 1 2- �n. � C� � � �f� r��$ 2 Z ' �.., � � '7 � �S � $ 3 � �, � 7�r 80 ,o$ a z � �� �� v �og s � � s 9 10 � `�.� �� ft of line x 65 gal. per 100 ft=��f10 �'�'8`�; 100 =��' ggal 75% x�2� ga1=l� gal per dose '3 � gal per minute (gpm) = I�'low Rate Frictio Head Loss: � 7 S� ft per 100 of supply line x�`3 � ft af supply. line =100 = 2• � ft `1� ft x 1.2 =� ft of friction head �. Manifold Size: �" Force Main Size: a " PVC TotaI Dynamic Head =�S ft of Elevadon head +� ft of Pressure head +� ft of Friction Head = �TDH Pump Require ent• � GPM @ 3 0• ft of Head Drawdown: ��al per dose � 21 gal per inch =�� inch drawdown per dose General De,tign gnformatlon � � .. . .., .. rv�crma+v.toe sa�ea�aarvcT� ���ar . • r�w ' � � � .� 1 � �[(�ii�o�c�o ���+lf�l������Y�������������.��� •.i*i�.����:�.�.�����:�:���.��.����.���"�� � a :� : v• 4 3" srz� � � Taps No. Taps ofioue I 6vv � 4i1+ � s t � s.� i . . . . y � ' Fiow er Tu Size ll�Cnerial FToiv G?1�( !; " Sclied 80 �•3 . f�= " Sched 40 ?.1 q, " �ched 80 1 Q,1 =% � Sclied s0 IZ.� > � 7 � . ���� �� �. , _ �',�, �, , _ ..: _ � � ���� . IE�� �;�9.�-���-�.��.��.71 IF7I�;�:IL� ' : WELL PERNIIT , PLEASE SEE ATTACHED PLAN FOR WELL SITE LAYOUT Tax Map !'�7 Parcel # 2o Township: A licant• 1�-� c� PP Subdivision: Lot # Location: Type of Water Supply: � Individual _ Community Requirements: Site Approved By: Grouting Approved By: Well Log: Pump Tag: Well Tag: Air Vent: Hose Bib: Casing Height: � Concrete Slab: Well Driller: Well Approved by: ****See Attached Site 5ketch**** Public Liner: Installed by: Depth set: _ Grouted• Date: Water Sample: Wells must be 10 feet from property lines. Wells must be 100 feet from septic systems. Wells must be at least 25 feet from any building foundation. Other conditions: Date: PCHD rev O1/27/04